8
Treatment

Substantial progress has been made in our knowledge of drug abuse treatment. Much of the treatment research was made possible by expansion of research funding by the National Institute on Drug Abuse (NIDA). Research has shown that drug abuse treatment is both effective and cost-effective in reducing not only drug consumption but also the associated health and social consequences. This chapter begins with a discussion of the need for treatment and then presents the many accomplishments in drug abuse treatment including the range of treatment options available (e.g., pharmacotherapies and psychosocial treatments), treatment effectiveness, the cost-effectiveness of treatment, and the development of tools and techniques for clinical assessment and diagnostic differentiation. The remainder of the chapter discusses opportunities for future research on medications development, treatment of HIV-infected drug abusers, matching patients to treatment options, treatment of patients with co-occurring psychiatric disorders and drug abuse, and treatment of drug abuse in special populations.

OVERVIEW OF DRUG ABUSE TREATMENT

Treatment is clearly indicated for individuals diagnosed with drug dependence, the most serious of the three levels of drug consumption—use, abuse, and dependence (see definitions in Chapter 1). Drug dependence occurs when a person has met three or more of the seven DSM-IV criteria items for dependence within the last year (see Appendix C for



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Pathways of Addiction: Opportunities in Drug Abuse Research 8 Treatment Substantial progress has been made in our knowledge of drug abuse treatment. Much of the treatment research was made possible by expansion of research funding by the National Institute on Drug Abuse (NIDA). Research has shown that drug abuse treatment is both effective and cost-effective in reducing not only drug consumption but also the associated health and social consequences. This chapter begins with a discussion of the need for treatment and then presents the many accomplishments in drug abuse treatment including the range of treatment options available (e.g., pharmacotherapies and psychosocial treatments), treatment effectiveness, the cost-effectiveness of treatment, and the development of tools and techniques for clinical assessment and diagnostic differentiation. The remainder of the chapter discusses opportunities for future research on medications development, treatment of HIV-infected drug abusers, matching patients to treatment options, treatment of patients with co-occurring psychiatric disorders and drug abuse, and treatment of drug abuse in special populations. OVERVIEW OF DRUG ABUSE TREATMENT Treatment is clearly indicated for individuals diagnosed with drug dependence, the most serious of the three levels of drug consumption—use, abuse, and dependence (see definitions in Chapter 1). Drug dependence occurs when a person has met three or more of the seven DSM-IV criteria items for dependence within the last year (see Appendix C for

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Pathways of Addiction: Opportunities in Drug Abuse Research DSM-IV criteria) (APA, 1994). As a consequence of compulsive drugseeking behavior and loss of control over consumption, drug dependence is usually a chronically relapsing disorder (i.e., one that may persist indefinitely and is prone to recur even after periods of remission). A diagnosis of drug abuse may also require treatment, but most clients in treatment have the more serious diagnosis of dependence. The number of heavy drug users, using at least once a week, is difficult to determine. It has been estimated that in 1993, there were 2.1 million heavy cocaine users and 444,000-600,000 heavy heroin users (Rhodes et al., 1995). Although cocaine and heroin represent the major drugs of abuse for a large proportion of individuals who seek treatment, most patients abuse more than one drug. In addition, others seek help for abuse of marijuana, phencyclidine, benzodiazepines, other sedatives, or abuse of multiple drugs. It was estimated that in 1994, 3.6 million people in the U.S. had drug problems severe enough to need drug treatment services (ONDCP, 1996). The actual number of clients in treatment falls far short of this estimate. For example, the National Drug and Alcoholism Treatment Unit Survey (NDATUS) reported that almost 1.0 million people in 1993 were in private and public drug abuse treatment programs; approximately 20 percent of those in treatment were enrolled mainly for illicit drug abuse, 45 percent for alcohol, and 35 percent for combined alcohol and other drug dependencies (SAMHSA, 1995a). Although the figures are not comparable or definitive, the magnitude of the gap between the need for treatment and the use of treatment services is clear. There are many reasons for the inadequate number of clients in treatment, including insufficient public funding for drug abuse treatment, cutbacks in treatment availability in the private sector, an unwillingness of many clients to seek treatment, and the deterrent effect of being placed on a waiting list for treatment (IOM, 1990b). Treatment should be available to all who request it, and long waiting lists are counterproductive (Goldstein and Kalant, 1990). That is particularly true given recent studies (cited later in this chapter and elsewhere) that demonstrate the effectiveness and cost-effectiveness of treatment. ACCOMPLISHMENTS Clearly, the development of varied treatment modalities and interventions discussed below are major accomplishments of drug abuse research. They include treatment options (e.g., pharmacotherapies and/or psychosocial), treatment effectiveness, cost-effectiveness, and the development of tools and techniques for clinical assessment and diagnostic differentiation.

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Pathways of Addiction: Opportunities in Drug Abuse Research Treatment Options Treatment is provided in a variety of settings, and within each treatment setting a range of interventions may be available (e.g., pharmacotherapy, education, psychosocial treatment) (IOM, 1990a,b). Structured treatment programs are generally classified according to four major treatment modalities: methadone maintenance, outpatient drug-free programs, therapeutic communities, and chemical dependency programs. Methadone maintenance with counseling is the primary treatment option for opiate addiction (McLellan et al., 1993). Methadone maintenance treatment is provided in tightly regulated programs or clinics, which are almost universally located in outpatient facilities. Outpatient drug-free programs serve the largest share of patients in drug abuse treatment. The programs provide counseling as the predominant form of treatment, but there is great variation in the array and intensity of counseling services, the quality and training of treatment staff, and the composition of patients. Therapeutic communities are highly structured long-term residential programs lasting up to 18 months and tailored primarily to the hardcore user. Chemical dependency programs are short-term residential programs patterned after the 12-step model of treatment (for more detailed descriptions, see IOM, 1990b). Commonalities across all treatment settings include a combination of individual and group counseling, education, and/or pharmacotherapy. Additionally, treatment providers generally recommend that formal therapy be combined with participation in self-help groups such as Alcoholics Anonymous. Furthermore, patients are usually encouraged to continue self-help group participation after leaving formal treatment to reinforce abstinence and a healthy life-style, because relapse to dependence after periods of remission is common (Woody and Cacciola, 1994). The following sections separate pharmacotherapeutic and psychosocial treatment options, it should be understood, however, that those approaches are combined in most clinical settings. The utility of that approach has been demonstrated, and it has been shown that methadone alone for the treatment of opiate dependence was not as effective as a combined regimen of methadone and psychosocial services as a more comprehensive approach to treatment (McLellan et al., 1993). Pharmacotherapy Pharmacotherapies have been developed or are being tested for the full spectrum of clinical needs: overdose, detoxification,1 dependence, 1   Medications, including methadone and clonidine, are often used to detoxify drug abuse patients and to manage withdrawal symptoms.

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Pathways of Addiction: Opportunities in Drug Abuse Research and relapse prevention. NIDA's Medications Development Division has made important contributions in the development of pharmacotherapies for drug addiction and has served as a catalyst in promoting drug development (IOM, 1995b). Medications development for the treatment of heroin and cocaine addictions is discussed more fully in a recent Institute of Medicine report (IOM, 1995b). Two opiate agonist medications, methadone and LAAM (levo-alpha-acetylmethadol), have been approved for the treatment of opiate addiction. Agonists act by substituting at the opioid receptor site, thereby blocking the euphoria of subsequently administered opiates (via crosstolerance) and inhibiting the symptoms of acute and chronic abstinence. Methadone was approved for use in 1972, and there are currently an estimated 650 methadone maintenance programs throughout the United States (IOM, 1995a,b). The data supporting the efficacy of methadone maintenance have been reviewed extensively (e.g., Ball and Ross, 1991; Kreek, 1992). In 1993, LAAM was approved for use in treating opiate dependence; this medication has the advantage of requiring three doses per week rather than daily doses, thus freeing subjects from daily clinic attendance. Clinical guidelines for the use of each of these medications have recently been published by the Substance Abuse and Mental Health Services Administration (SAMHSA, 1993, 1995c). Naltrexone, an orally effective and long-acting opiate antagonist, has been shown effective in preventing relapse to opiate dependence in highly motivated patients (e.g., probationers, parolees, health care providers) who are under strong external pressure to remain opiate free (Brahen et al., 1978). Naltrexone has also been found to reduce relapse to alcohol dependence (Volpicelli et al., 1992). A newer opiate antagonist, nalmafene, which is currently undergoing testing, appears to have positive effects similar to those of naltrexone (Mason et al., 1994). Opiate antagonist medications work by binding to the opioid receptor site, preventing receptor activation by the abused drug and thereby blocking the drug's euphorigenic and dependence-producing effects. This blockade represents competitive antagonism, and thus its clinical efficacy can be modified by the dose of the antagonist, the time elapsed since the antagonist was taken, and the dose of the abused drug. Buprenorphine is a partial opiate agonist that produces less physiological dependence than methadone or LAAM and is currently in clinical trials (Bicket and Amass, 1995; Cowan and Lewis, 1995). It has been shown to be effective in maintenance therapy, in retaining patients in treatment, and in facilitating abstinence from illicit opiates Johnson et al., 1992; Kosten et al., 1993). Buprenorphine is currently being tested in combination with naloxone in a sublingual preparation to reduce its abuse liability. The eventual goal is to develop a pharmacotherapy that avoids

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Pathways of Addiction: Opportunities in Drug Abuse Research the strict scheduling controls that have been applied to methadone and LAAM. Fewer scheduling requirements would expand use to a wider range of settings (see IOM, 1995b). Psychosocial Treatments Psychosocial treatments include counseling, psychotherapy, and cognitive skills development. Counseling attempts to identify specific problems in the patient's life and to provide support, deliver concrete services, encourage abstinence, foster compliance with clinic rules, identify emergent problems, and refer the patient to more specialized services when needed (Woody et al., 1983). A series of well-designed studies has shown that drug counseling can produce substantial reductions in drug use and in the severity of problems that are associated with dependence. Those studies have been carried out in methadone programs (McLellan et al., 1982, 1988, 1993) and, more recently, in programs treating patients with cocaine and/or alcohol dependence (Rawson et al., 1993; Alterman et al., 1994, 1996; Shopshaw et al., 1995). In some instances, counseling may be provided by individuals who are recovering from drug dependencies and who have little formal education in health-related fields. Unlike counseling, which focuses mainly on concrete, external factors, psychotherapy strives to identify and modify maladaptive interpersonal processes. There are many types of psychotherapy and they differ according to their theoretical basis and focus. For example, cognitivebehavioral psychotherapy aims to identify and change false beliefs and their associated behaviors (Beck et al., 1990). Supportive-expressive psychotherapy attempts to identify and change repetitive and problematic relationships and behaviors (Luborsky, 1984; Luborsky et al., 1995). Interpersonal psychotherapy tries to identify and change current maladaptive interpersonal problems. Motivational enhancement therapy may be more appropriate for an individual in the precontemplative stage of drug abuse (see Prochaska and DiClemente, 1983, 1986 below). Two prospective studies done in methadone programs using random assignment and a range of measures have shown that these psychotherapies can provide additional benefits to patients with moderate to high levels of psychiatric symptoms (Woody et al., 1984, 1995b). An interesting area of research is contingency contracting, which applies behavioral methods of reinforcement to the treatment of drug abuse (Chapter 2). Contingency contracting involves the use of graduated rewards, which are given to patients when they meet specific treatment goals such as keeping appointments, seeking work, or providing drugfree urine samples. Rewards may include objects such as a lottery ticket or vouchers for the purchase of valued goods and services, methadone take-

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Pathways of Addiction: Opportunities in Drug Abuse Research home doses, or other socially appropriate rewards. Studies using this approach have found reductions in drug use among patients with heroin (Stitzer et al., 1992; Kidorf et al., 1994) or cocaine dependence (Higgins et al., 1993, 1994). The principles used in those studies have evolved from behavioral research, as summarized in Chapter 2. Most behavioral interventions have the advantage of being easily integrated within existing modalities. Treatment Effectiveness The effectiveness of treatment for drug addictions has been reviewed extensively (see Simpson and Sells, 1982, 1990; IOM, 1990b, 1995a,b; Prendergast et al., in press). Treatment gains are typically found in reduced intravenous and other drug use, reduced criminality, and enhanced health and productivity. The largest multisite studies, which are described below and cover multiple treatment modalities, provide strong evidence of long-term treatment effectiveness, usually based on comparisons between client behaviors before, during, and after treatment. The length of time in treatment consistently has been found to be an important determinant of both short- and long-term improvement. It is important to note, however, that most study results include the effects of patient self-selection in their preferred type of treatment modality. Although random assignment of patients to a treatment modality is preferred, it is difficult to achieve because of regulatory constraints, treatment facility capacities, study design, and ethical considerations. Three comprehensive studies of drug abuse treatment effectiveness are discussed. The first study, the Drug Abuse Reporting Program (DARP), included more than 44,000 clients entering more than 50 treatment programs from 1969 to 1973 (Simpson and Sells, 1982, 1990). A subset of the cohort was studied 6 and 12 years after treatment. The second study is the Treatment Outcome Prospective Study (TOPS), which included almost 12,000 clients in 41 treatment programs (Hubbard et al., 1989). Clients were followed up to five years after treatment. The final study, which is still in progress, is the Drug Abuse Treatment Outcome Study (DATOS). The first two studies, DARP and TOPS, both found evidence of treatment effectiveness for methadone maintenance, outpatient drug-free programs, and residential treatment (in therapeutic communities). Posttreatment outcomes were associated directly with the duration of treatment, with three months as the minimum time in treatment to observe an effect. Both DARP and TOPS found major reductions in the use of drugs and in criminal activity. TOPS also found modest improvements in productivity. In DARP, for example, the long-lasting nature of improvement was in

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Pathways of Addiction: Opportunities in Drug Abuse Research evidence 12 years after treatment, but most of the improvement was attained in the first 3 years after treatment. The results of these and other studies collectively indicate that 30-50 percent of patients are able to remain abstinent one year after the completion of treatment (McLellan et al., in press, a). These gains are comparable to those seen in treatment for other chronic, relapsing disorders. Studies that compared compliance of patients in drug treatment with that of patients being treated for hypertension, adult onset diabetes, and asthma found that to remain symptomfree, each of these medical conditions requires patients to undergo major changes in life-style, often accompanied by medication (O'Brien and McLellan, 1996; McLellan et al., in press, a). Less than 30 percent of patients being treated for diabetes and hypertension were found to comply with dietary and other behavioral recommendations, and less than 30 percent of those with hypertension or asthma comply with their medication schedules. DATOS, the final large-scale treatment outcome study begun in the early 1990s, enrolled 10,000 clients, one-third of whom were women, to determine the effectiveness of about 99 programs throughout the country. Four major modalities are under investigation: methadone maintenance, outpatient drug-free, long-term residential, and short-term inpatient programs (R. Hubbard, Research Triangle Institute, personal communication, 1995). Treatment Cost-Benefit and Cost-Effectiveness Drug abuse treatment is a judicious public investment and is less expensive than the alternatives (Figure 8.1). TOPS, cited above, performed a cost-benefit analysis2 by comparing the cost of treatment with the benefits (i.e., cost savings) of reduced crime and increased productivity during treatment and one year afterward. The ratio of benefits to costs for each treatment modality ranged from 4:1 to 1:1, depending on which of two complex scenarios was used to calculate societal benefits (Hubbard et al., 1989). The economic benefits of reduced crime, enhanced productivity, and lower health care utilization were captured in a more recent study (Gerstein et al., 1994). This study, the first cost-benefit study to include the benefit of lower health care utilization, was undertaken by the State of California on 3,000 clients discharged from treatment programs in 1992. 2   A cost-benefit analysis assigns monetary values to all of the costs and benefits of a program or policy to determine whether the benefits outweigh the costs.

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Pathways of Addiction: Opportunities in Drug Abuse Research FIGURE 8.1 Treatment is less expensive than alternatives. NOTE: a1991 dollars; b1992 dollars; C1993 dollars; d1992 dollars, inflation adjusted from 1983 data; ethe average cost per admission is much lower than this figure because most patients are in treatment less than one year. SOURCES: Lewin-VHI, unpublished estimates; McLellan et al. (1994); Rydell and Everingham (1994); SAMHSA (1994a). The study group consisted of a random sample of 150,000 clients in treatment programs throughout the state. By comparing the one-year period before treatment with the one-year period after, substantial benefits were realized relative to the cost of treatment. According to two different benefit measures, the ratio of benefits to costs was about 7:1 or 2:1 when all treatment modalities were combined. Health care costs for the sample were lowered after treatment by 23.5 percent; these savings alone offset about 55 percent of the cost of a treatment episode. Most of the economic benefits from both the TOPS and the California studies came in the form of reduced crime-related costs. The cost-effectiveness3 of treatment has also been assessed in comparison with other drug control strategies (Everingham and Rydell, 1994; Rydell and Everingham, 1994). Investigators found treatment programs to be far more cost-effective than a range of drug control strategies in reducing cocaine use. The study analyzed the costs required by four different strategies-treatment, domestic enforcement, interdiction, and 3   A cost-effectiveness analysis strives to identify which of the different programs can attain a desired objective at the lowest cost (Center of Alcohol Studies, 1993).

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Pathways of Addiction: Opportunities in Drug Abuse Research FIGURE 8.2 Effectiveness of cocaine control strategies. The RAND study compared treatment (a demand control strategy) and three supply control strategies: source country control, interdiction, and domestic enforcement. It calculated the cost required for each strategy to acheive a common measure of effectiveness-a reduction in cocaine consumption by 1 percent of current annual consumption. To meet this objective, researchers found that the additional cost of treatment would be $34 million, an amount 7.3 times less than that needed for the next most effective strategy, domestic enforcement, and 23 times less expensive than source country control. SOURCE: Rydell and Everingham (1994). source country control-to achieve a 1 percent reduction in cocaine consumption. Treatment cost the least ($34 million) to achieve the objective, whereas other strategies cost between $250 million and $800 million (Figure 8.2). Thus, treatment was determined to be 7.3 times less costly than the least expensive alternative and more than 20 times less costly than the most expensive strategy, source country control. It should be pointed out that all of these cost-benefit studies examined ''effectiveness" from a societal point of view and found treatment to be a wise public investment. However, studies did not address critical questions facing providers regarding the most cost-effective treatments. There are only a few studies comparing the relative cost-effectiveness of different treatments. That information gap is discussed in Chapter 9. Clinical Assessment and Diagnostic Differentiation Research advances in diagnosis have made it possible to conduct

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Pathways of Addiction: Opportunities in Drug Abuse Research detailed assessments of clients in treatment. Among these advances has been the development of instruments that reliably assess drug abuse and dependence and co-occurring psychiatric disorders according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 1994) and the International Classification of Diseases (ICD-10; WHO, 1992). Some of the most commonly used instruments are the Composite International Diagnostic Interview (CIDI); the Substance Abuse Module of the CIDI (the CIDI-SAM); the Diagnostic Interview Schedule (DIS); and the Structured Clinical Interview for DSM-IV (SCID). Work is currently under way to modify them to improve the distinctions between primary psychiatric disorders and drug-produced psychiatric syndromes in order to further improve treatment (D. Hasin, 1995 New York State Psychiatric Institute, personal communication). Other instruments have been developed to assess the severity of patients' problems and their need for treatment across a wider range of areas. Among these, the most widely used is the Addiction Severity Index (ASI), which was developed in the early 1980s with research funds from both NIDA and the Department of Veterans Affairs (VA). ASI measures the degree of impairment and the need for treatment in each of seven areas commonly affected by drug abuse: drug and alcohol use, medical, family or social, employment, legal, and psychiatric (McLellan et al., 1980). The ASI has been found to be reliable and applicable within a wide range of settings, provided that appropriate training has been given to those who administer it. Unlike CIDI, DIS, and SCID, ASI does not make diagnoses but rather quantifies the degree to which impairment exists (and treatment is needed) in each of the seven areas. It is often used in clinical practice for evaluation and treatment planning. One immediate positive effect of newer assessment techniques is the development of improved descriptions of patients. A very consistent finding, from a large number of studies using one or more of these assessment measures, is that the patient population is often engaged in polydrug use (i.e., use of a variety of illicit drugs and alcohol) and has other serious current or past problems in addition to drug abuse (e.g., psychiatric, employment, family/social problems) (Rounsaville et al., 1982; McLellan et al., 1994). These findings have been useful in developing treatment matching strategies (discussed below). Advances in diagnosis have also led to comprehensive and accurate methods for assessing outcomes. The ASI has been particularly useful because it can measure degrees of improvement when administered on repeated occasions before, during, and after treatment. In treatment outcome studies, the ASI is usually supplemented with other measures such as urinalysis, breath alcohol tests, structured interviews for assessing psy-

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Pathways of Addiction: Opportunities in Drug Abuse Research chiatric disorders, measures of psychiatric symptoms, arrest and employment records, and interviews with family members. A newer assessment instrument that derives from the ASI is the Treatment Services Review (TSR). It is administered by a trained technician at periodic intervals during an episode of treatment, and it measures the services actually delivered in each of the areas assessed by ASI (McLellan et al., 1992). By using the TSR along with the ASI, treatment outcome can be measured against services actually received. Early studies using ASI and TSR show that patients generally improve if they receive the services they need and usually do not improve if services are not tailored to their needs (McLellan et al., 1994). Thus, programs may also be assessed on how effectively they have addressed the needs of patients. RESEARCH OPPORTUNITIES The continued research challenge will be to develop more effective and cost-effective pharmacotherapeutic and psychosocial treatments that address the specific needs of individual patients and to refine the tools and techniques for clinical assessment and diagnostic differentiation. Questions remain regarding the different outcomes among programs using the same treatment modality; studies are needed to evaluate those program characteristics that produce the most efficacious results (e.g., the degree to which programs are willing to retain patients with persistent "dirty" urines or other signs of less than optimal progress, or the degree to which difficult patients are accepted into treatment). Furthermore, while long-term methadone maintenance has proven to be effective (Ball and Ross, 1991), questions remain regarding the length of time patients remain in treatment. Studies consistently have demonstrated that as long as patients are in methadone maintenance treatment there is a reduction in drug abuse. However, relapse to prior drug use occurs when treatment is terminated (IOM, 1990b; Ball and Ross, 1991). These findings have serious implications for HIV transmission as current data show that HIV infection is more likely among those who leave treatment than those who remain in treatment (e.g., Metzger and coworkers [1993] found that 4 percent of injection drug users who remained in treatment for the first 18 months became HIV infected, as compared with 22 percent of those not in treatment). Additionally, research in medications development, HIV/AIDS and injection drug use, treating patients with co-occurring psychiatric disorders and drug abuse, and treating special populations of drug abusers is critical to fully meet the treatment needs of this population and to reduce the associated social and health consequences to society. These issues are discussed more fully below.

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Pathways of Addiction: Opportunities in Drug Abuse Research ders. One controversial group of pharmacotherapies for anxiety disorders among patients with drug abuse has been benzodiazepines. They are generally considered safe and effective for a range of anxiety disorders and are among the most widely used pharmacotherapies (Tyrer, 1984). However, there is clear evidence that some benzodiazepines have a significant abuse liability (Sellers et al., 1993). Consequently, the use of benzodiazepines in patients with a history of drug abuse or dependence is often judged to be contraindicated. However, not all benzodiazepines are equally prone to abuse. Medications such as oxazepam, clorazepate, or others with longer duration to onset of peak effect not only might be useful in treating patients with co-occurring anxiety, but may have little risk of abuse when taken orally. Studies to determine the usefulness of benzodiazepines with slow onset to peak effects for patients with drug abuse and anxiety disorders would be helpful in providing data on this issue. Additionally, since U.S. drug abusers often abuse multiple drugs, studies are needed to determine the interactions among drugs of abuse, medications used to treat drug dependence, and medications used to treat comorbid psychiatric and medical disorders. For example, a medication intended to prevent relapse to cocaine dependence should be tested for adverse consequences when used in combination with alcohol or opiates since these drugs are commonly used together. This is an area in which the behavioral models discussed in Chapter 2 could make significant contributions. Further, pharmacokinetic studies of medications are typically carried out in healthy individuals, whereas many drug abusers have multiple health problems. Thus, the interactions among abused drugs, medications for drug abuse or dependence, and medications for psychiatric and medical problems may be altered in drug abusers. To optimize treatment strategies and to prevent adverse health outcomes, pharmacokinetic studies are needed to determine these possible interactions. Additionally, comparative studies of pharmacotherapies and psychotherapies for specific, well-defined depressive or anxiety disorders with this population (drug abuse and psychiatric disorders) could provide important data about the most appropriate therapies. Special Populations There is a dearth of research on drug-abusing women, prisoners, and adolescents. For reasons discussed below, it is extremely important for those populations to gain access to, enter, and remain in treatment. Most of the research opportunities center on treatment access, retention, and

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Pathways of Addiction: Opportunities in Drug Abuse Research effectiveness. There are large gaps in our knowledge of these areas, much of which is attributable to methodological difficulties. Women The health consequences of drug abuse can be more serious for women than for men, in spite of the fact that fewer women abuse drugs. Women can contract HIV through injection drug use or prostitution to purchase drugs. Maternal drug use can result in transmitting the disease to their fetus, premature delivery with serious complications, and impairments in parenting. Yet research has documented more barriers to treatment entry for female than for male alcoholics (Weisner and Schmidt, 1992; Schmidt and Weisner, 1995). Some of the obstacles for women are the cost of treatment, the possible loss of custody of their children, and the lack of child care (Beckman, 1994). Similar barriers to treatment may be operating for male drug abusers, but the extent of the problem is unknown. A recent study of more than 12,000 clients in treatment found that women tended to drop out of treatment at higher rates than men (Mammo and Weinbaum, 1993). It is possible that women have difficulty making child care arrangements, fear retribution, or feel uncomfortable talking about their problems when being treated in programs that are predominantly male. Some programs, in an attempt to overcome these barriers, have experimented with women-only groups and with on-site facilities for child care. Studies have also shown that women with drug abuse disorders typically have more psychiatric disorders (including depression and anxiety) than males (Blume, 1992). Many drug-dependent women have been sexually abused as children, suffer from posttraumatic stress disorder, and have significant problems forming healthy relationships with males (SAMHSA, 1994b). Abusive relationships with drug-abusing males are common, sometimes characterized by situations in which the male exerts control by providing drugs. These complex issues indicate that psychiatric assessment and treatment constitute a particularly important aspect of drug abuse treatment for women. Few studies have been done to examine the effect of integrating psychiatric treatment into the ongoing services of programs that treat drug-abusing women. In spite of those problems, research shows that when women remain in treatment, they benefit just as much as men do (Sanchez-Craig et al., 1989; Ball and Ross, 1991; Finnegan, 1991). Methadone maintenance programs for pregnant women are the best studied, but outcomes in many other settings indicate that women benefit at least as much as men from the range of treatments that are currently available (Hubbard et al., 1989;

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Pathways of Addiction: Opportunities in Drug Abuse Research IOM, 1990a). There is a dearth of studies on programs that deliver services tailored to women's needs. Problems continue to be greatest for pregnant women. In the past, many treatment programs automatically excluded pregnant women because of liability concerns or concerns about lack of expertise with medical complications of pregnancy. Some areas of the country have enacted laws that classify drug abuse during pregnancy as a form of child abuse, which would lead to the placement of children in foster care. These laws do not seem to reduce drug abuse, but they may have the negative effect of discouraging pregnant drug users from seeking treatment (see Chapter 10). Exclusion of pregnant women from treatment programs is beginning to diminish, however. A recent survey of 294 drug treatment programs in five cities revealed that the majority of programs (70-83 percent) accepted pregnant women. Fewer programs, however, accepted women who were Medicaid recipients, and even fewer programs provided child care (Breitbart et al., 1994). When pregnant women succeed in gaining access to treatment, they face yet another hurdle—the lack of pharmacotherapies specifically approved for use in pregnancy (IOM, 1995b). This problem is true for medications of all kinds, not just for those used in drug abuse treatment. Pharmaceutical firms rarely, if ever, seek Food and Drug Administration (FDA) approval for use of their products in pregnancy, mostly because of liability concerns. When pregnant heroin drug users, for example, need treatment to reduce drug use and the risk of HIV transmission to themselves and their unborn, their doctors are strongly discouraged by federal treatment regulations and by the manufacturer from prescribing LAAM. According to federal treatment regulations, pregnant women are offered methadone, which is not formally approved by the FDA for use in pregnancy. FDA has drafted guidelines recommending that future studies of antiaddiction medications include women, but the guidelines do not provide advice for a mechanism dealing with increased risk for product liability (Woody et al., 1996). Prisoners Treatment programs have recently become more prominent in some correctional settings, with therapeutic communities among the most common modalities. The therapeutic community provides a total treatment environment isolated from the rest of the prison population—separated from the drugs, the violence, and the norms and values that mitigate against treatment, habilitation, and rehabilitation. Treatment programs based in correctional settings sometimes include aftercare in the community after release from prison. Although therapeutic communities appear

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Pathways of Addiction: Opportunities in Drug Abuse Research to be the most visible drug abuse treatment programs in correctional settings, there are numerous other modalities, many of which are grounded in individual and group counseling and 12-step approaches. However, there is limited information about these programs in the drug abuse literature. There are virtually no methadone maintenance programs offered in correctional settings, which is most likely a result of policies to eliminate the availability of a medication that is itself a controlled drug. Most treatment of drug-involved offenders takes place in community-based settings as a condition of parole or probation or in lieu of prison. Treatment in the community is made possible through programs that link the criminal justice system with specialty drug abuse treatment programs. The most prominent example is Treatment Alternatives to Street Crime (TASC), whose programs are found in more than 25 states (Inciardi and McBride, 1991). Evaluation data indicate that TASC-referred clients remain in treatment longer than non-TASC clients (court referrals to treatment without TASC services). Other programs linking treatment to parole and probation have experienced favorable results (Chavaria, 1992; Van Stelle et al., 1994). Although there are extensive studies of drug-involved offenders who are treated effectively in community settings, there is a dearth of information about drug treatment programs in prisons or about the best means of treating drug abusers in these settings. What is known is that for the few prisoners who succeed in gaining access to a limited number of prisonbased therapeutic communities, treatment is effective. Many in the drug treatment community believe that prisoners have the most profound treatment system needs in light of the pervasive violence and widespread availability of illicit drugs within the prison system. The co-occurrence of addictive and severe psychiatric disorders is also highest in the prison population (Regier et al., 1990). Adolescents Adolescents are also vulnerable to the consequences of drug abuse, including health effects, accidents and injuries, involvement with violence resulting from illegal activities, and the transmission of HIV (Czechowicz, 1991). Adolescent drug abusers differ from adult drug abusers in several ways that are significant for treatment. The majority of adolescent drug abusers have a shorter history of drug abuse; have less severe symptoms of tolerance, craving, and withdrawal; and usually do not have the long-term physical effects of drug abuse (Kaminer, 1994). However, they are at the greatest risk for developing lifelong patterns of drug abuse (Dusenbury et al., 1992). Adolescents accounted for about 11.1 percent of all patients in spe-

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Pathways of Addiction: Opportunities in Drug Abuse Research cialty drug abuse treatment programs in 1993 (SAMHSA, 1995a), down from 16.9 percent in 1987, although their proportion appears to be rising again (SAMHSA, 1995a). There is increasing recognition of the need to implement and evaluate treatment programs designed specifically for adolescents (IOM, 1990b). A new study of treatment effectiveness for 3,000 adolescents enrolled in standard treatment programs is under way, with findings to be reported in 1997 (R. Hubbard, Research Triangle Institute, personal communication, 1995). There are additional opportunities to design and evaluate the effectiveness of special programs with services tailored to adolescents. Results from such studies will enable the development of targeted treatment and prevention programs. RECOMMENDATION Substantial progress has been made during the past 20 years in our knowledge of drug abuse treatment. Research has shown that drug abuse treatment is both effective and cost-effective in reducing not only drug consumption but also the associated health and social consequences. Continued research on drug abuse treatment is needed in many priority areas. The committee recommends that the appropriate federal and private agencies continue to support research to improve and evaluate the effectiveness of drug abuse treatment. This includes studies on optimal strategies for matching patients to the most appropriate treatment modalities; development of medications for the treatment of drug abuse and dependence; the efficacy of pharmacotherapies and psychosocial therapies to treat individuals with co-occurring psychiatric disorders and drug abuse; the natural history of HIV infection among drug users and effective models of health care delivery for HIV-infected drug abusers; and the efficacy of treatment programs designed toward addressing the needs of special populations (i.e., women, adolescents, and prisoners). REFERENCES Alterman Al, O'Brien CP, McLellan AT, August DS, Snider EC, Droba M, Cornish JW, Hall CP, Raphaelson AH, Schrade FX. 1994. Effectiveness and costs of inpatient versus day hospital cocaine rehabilitation. Journal of Nervous and Mental Disease 182:157-163. Alterman Al, Snider EC, Cacciola JS, May DJ, Parikh G, Maany I, Rosenbaum PR. 1996. Treatments for cocaine dependence. Journal of Nervous and Mental Disease 184(1):54-56. APA (American Psychiatric Association). 1994. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Washington, DC: APA. Ball JC, Ross A. 1991. The Effectiveness of Methadone Maintenance Treatmnent. New York: Springer-Verlag.

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